Editing Aphasia (section)

==Management==

Most acute cases of aphasia recover some or most skills by participating in [[Speech–language pathology|speech and language therapy]]. Recovery and improvement can continue for years after the stroke. After the onset of aphasia, there is approximately a six-month period of spontaneous recovery; during this time, the brain is attempting to recover and repair the damaged neurons. Improvement varies widely, depending on the aphasia's cause, type, and severity. Recovery also depends on the person's age, health, motivation, [[handedness]], and educational level.<ref name="medicinenet.com" />

Speech and language therapy that is higher intensity, higher dose or provided over a long duration of time leads to significantly better functional communication, but people might be more likely to drop out of high intensity treatment (up to 15 hours per week).<ref name="Brady2016">{{cite journal |vauthors=Brady MC, Kelly H, Godwin J, Enderby P, Campbell P |date=June 2016 |title=Speech and language therapy for aphasia following stroke |journal=The Cochrane Database of Systematic Reviews |volume=2016 |issue=6 |pages=CD000425 |doi=10.1002/14651858.CD000425.pub4 |pmc=8078645 |pmid=27245310 |hdl-access=free |hdl=1893/26112}}</ref> A total of 20–50 hours of speech and language therapy is necessary for the best recovery. The most improvement happens when 2–5 hours of therapy is provided each week over 4–5 days. Recovery is further improved when besides the therapy people practice tasks at home.<ref name=":7">{{Cite journal |last1=Brady |first1=Marian C |last2=Ali |first2=Myzoon |last3=VandenBerg |first3=Kathryn |last4=Williams |first4=Linda J |last5=Williams |first5=Louise R |last6=Abo |first6=Masahiro |last7=Becker |first7=Frank |last8=Bowen |first8=Audrey |last9=Brandenburg |first9=Caitlin |last10=Breitenstein |first10=Caterina |last11=Bruehl |first11=Stefanie |last12=Copland |first12=David A |last13=Cranfill |first13=Tamara B |last14=di Pietro-Bachmann |first14=Marie |last15=Enderby |first15=Pamela |date=October 2022 |title=Complex speech-language therapy interventions for stroke-related aphasia: the RELEASE study incorporating a systematic review and individual participant data network meta-analysis |url=https://www.journalslibrary.nihr.ac.uk/hsdr/RTLH7522 |journal=Health and Social Care Delivery Research |language=en |volume=10 |issue=28 |pages=1–272 |doi=10.3310/RTLH7522 |pmid=36223438 |issn=2755-0060|doi-access=free |hdl=10072/419101 |hdl-access=free }}</ref><ref name=":8">{{Cite journal |last= |first= |date=2023-09-01 |title=Speech and language therapy for aphasia after a stroke |url=https://evidence.nihr.ac.uk/alert/therapy-for-language-problems-after-a-stroke-is-most-effective-when-given-early-and-intensively/ |access-date=2023-09-08 |website=NIHR Evidence |publisher=National Institute for Health and Care Research |language=en-GB |type=Plain English summary |doi=10.3310/nihrevidence_59653|s2cid= 261470072}}</ref> Speech and language therapy is also effective if it is [[Telerehabilitation|delivered online through video]] or by a family member who has been trained by a professional therapist.<ref name=":7" /><ref name=":8" />

Recovery with therapy is also dependent on the recency of stroke and the age of the person. Receiving therapy within a month after the stroke leads to the greatest improvements. Three or six months after the stroke more therapy will be needed, but symptoms can still be improved. People with aphasia who are younger than 55 years are the most likely to improve, but people older than 75 years can still get better with therapy.<ref name=":7" /><ref name=":8" />

There is no one treatment proven to be effective for all types of aphasias. The reason that there is no universal treatment for aphasia is because of the nature of the disorder and the various ways it is presented. Aphasia is rarely exhibited identically, implying that treatment needs to be catered specifically to the individual. Studies have shown that, although there is no consistency on treatment methodology in literature, there is a strong indication that treatment, in general, has positive outcomes.<ref name="Schmitz O'Sullivan 2007">{{cite book |author1=Schmitz, Thomas J. |author2=O'Sullivan, Susan B. |title=Physical rehabilitation |publisher=F.A. Davis |location=Philadelphia |year=2007 |isbn=978-0-8036-1247-1 |oclc= 70119705 }}</ref> Therapy for aphasia ranges from increasing functional communication to improving speech accuracy, depending on the person's severity, needs and support of family and friends.<ref>{{cite web|url=http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934663&section=Treatment|title=Aphasia|work=asha.org}}</ref> Group therapy allows individuals to work on their pragmatic and communication skills with other individuals with aphasia, which are skills that may not often be addressed in individual one-on-one therapy sessions. It can also help increase confidence and social skills in a comfortable setting.<ref name="Manasco" />{{Reference page|97}}

Evidence does not support the use of [[Transcranial direct-current stimulation|transcranial direct current stimulation]] (tDCS) for improving aphasia after stroke. Moderate quality evidence does indicate naming performance improvements for nouns, but not verbs using tDCS<ref>{{Cite journal|last1=Elsner|first1=Bernhard|last2=Kugler|first2=Joachim|last3=Pohl|first3=Marcus|last4=Mehrholz|first4=Jan|date=21 May 2019|title=Transcranial direct current stimulation (tDCS) for improving aphasia in adults with aphasia after stroke|journal=The Cochrane Database of Systematic Reviews|volume=2019|issue=5 |pages=CD009760|doi=10.1002/14651858.CD009760.pub4|issn=1469-493X|pmc=6528187|pmid=31111960}}</ref>

Specific treatment techniques include the following:
* Copy and recall therapy (CART) – repetition and recall of targeted words within therapy may strengthen orthographic representations and improve single word reading, writing, and naming<ref>Beeson, P. M., Egnor, H. (2007), Combining treatment for written and spoken naming, Journal of the International Neuropsychological Society, 12(6); 816–827.</ref>
* Visual communication therapy (VIC) – the use of index cards with symbols to represent various components of speech
* Visual action therapy (VAT) – typically treats individuals with global aphasia to train the use of hand gestures for specific items<ref>"Aphasia". American Speech Language Hearing Association. Retrieved from http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934663&section=Treatment {{Webarchive|url=https://web.archive.org/web/20201001222338/https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934663&section=Treatment |date=2020-10-01 }}</ref>
* Functional communication treatment (FCT) – focuses on improving activities specific to functional tasks, social interaction, and self-expression
* Promoting aphasic's communicative effectiveness (PACE) – a means of encouraging normal interaction between people with aphasia and clinicians. In this kind of therapy, the focus is on pragmatic communication rather than treatment itself. People are asked to communicate a given message to their therapists by means of drawing, making hand gestures or even pointing to an object<ref>{{cite book | vauthors = Alexander MT, Hillis AE | title = Neuropsychology and Behavioral Neurology: Handbook of Clinical Neurology | chapter = Aphasia | volume = 88 | veditors = Goldenberg G, Miller BL, Aminoff MJ, Boller F, Swaab DF | publisher = Elsevier Health Sciences | year = 2008 | pages = 287–310 | isbn = 978-0-444-51897-2 | oclc= 733092630}}</ref>
* Melodic intonation therapy (MIT) – aims to use the intact melodic/prosodic processing skills of the right hemisphere to help cue retrieval of words and expressive language<ref name="Manasco" />{{Reference page|93}}
* Centeredness Theory Interview (CTI) - Uses client centered goal formation into the nature of current patient interactions as well as future / desired interactions to improve subjective well-being, cognition and communication.<ref>{{Cite web |title=APA PsycNet |url=https://psycnet.apa.org/record/2021-16502-008 |access-date=2023-03-21 |website=psycnet.apa.org |language=en}}</ref>
* Other – ''i.e.'', drawing as a way of communicating, trained conversation partners<ref name="Schmitz O'Sullivan 2007" />

Semantic feature analysis (SFA)&nbsp;— a type of aphasia treatment that targets word-finding deficits&nbsp;— is based on the theory that neural connections can be strengthened by using related words and phrases that are similar to the target word, to eventually activate the target word in the brain. SFA can be implemented in multiple forms such as verbally, written, using picture cards, etc. The SLP provides prompting questions to the individual with aphasia in order for the person to name the picture provided.<ref>{{cite journal | author = Davis , Stanton | year = 2005 | title = Semantic Feature Analysis as a Functional Therapy Tool | journal = Contemporary Issues in Communication Science and Disorders | volume = 35 | pages = 85–92 | doi = 10.1044/cicsd_32_F_85 }}</ref> Studies show that SFA is an effective intervention for improving confrontational naming.<ref>{{cite journal | vauthors = Maddy KM, Capilouto GJ, McComas KL | title = The effectiveness of semantic feature analysis: an evidence-based systematic review | journal = Annals of Physical and Rehabilitation Medicine | volume = 57 | issue = 4 | pages = 254–267 | date = June 2014 | pmid = 24797214 | doi = 10.1016/j.rehab.2014.03.002 | doi-access = free }}</ref>

[[Melodic intonation therapy]] is used to treat non-fluent aphasia and has proved to be effective in some cases.<ref>{{cite journal | vauthors = Norton A, Zipse L, Marchina S, Schlaug G | title = Melodic intonation therapy: shared insights on how it is done and why it might help | journal = Annals of the New York Academy of Sciences | volume = 1169 | pages = 431–436 | date = July 2009 | pmid = 19673819 | pmc = 2780359 | doi = 10.1111/j.1749-6632.2009.04859.x }}</ref> However, there is still no evidence from [[randomized controlled trial]]s confirming the efficacy of MIT in chronic aphasia. MIT is used to help people with aphasia vocalize themselves through speech song, which is then transferred as a spoken word. Good candidates for this therapy include people who have had left hemisphere strokes, non-fluent aphasias such as Broca's, good auditory comprehension, poor repetition and articulation, and good emotional stability and memory.<ref>{{cite journal | vauthors = van der Meulen I, van de Sandt-Koenderman ME, Ribbers GM | title = Melodic Intonation Therapy: present controversies and future opportunities | journal = Archives of Physical Medicine and Rehabilitation | volume = 93 | issue = 1 Suppl | pages = S46–52 | date = January 2012 | pmid = 22202191 | doi = 10.1016/j.apmr.2011.05.029 }}</ref> An alternative explanation is that the efficacy of MIT depends on neural circuits involved in the processing of rhythmicity and [[formulaic language|formulaic expressions]] (examples taken from the MIT manual: "I am fine," "how are you?" or "thank you"); while rhythmic features associated with melodic intonation may engage primarily left-hemisphere subcortical areas of the brain, the use of formulaic expressions is known to be supported by right-hemisphere cortical and bilateral subcortical neural networks.<ref name="Sidtis 2015" /><ref>{{cite journal | vauthors = Stahl B, Kotz SA | title = Facing the music: three issues in current research on singing and aphasia | journal = Frontiers in Psychology | volume = 5 | issue = 1033 | pages = 1033 | year = 2013 | pmid = 25295017 | pmc = 4172097 | doi = 10.3389/fpsyg.2014.01033 | doi-access = free }}</ref>

Systematic reviews support the effectiveness and importance of partner training.<ref>{{Cite journal | doi=10.1016/j.apmr.2016.03.023| pmid=27117383| title=Communication Partner Training in Aphasia: An Updated Systematic Review| journal=Archives of Physical Medicine and Rehabilitation| volume=97| issue=12| pages=2202–2221.e8| year=2016| last1=Simmons-Mackie| first1=Nina| last2=Raymer| first2=Anastasia| last3=Cherney| first3=Leora R.}}</ref> According to the National Institute on Deafness and Other Communication Disorders (NIDCD), involving family with the treatment of an aphasic loved one is ideal for all involved, because while it will no doubt assist in their recovery, it will also make it easier for members of the family to learn how best to communicate with them.<ref name="Aphasia">{{cite web |url=https://www.nidcd.nih.gov/health/aphasia |title=Aphasia |website=National Institute on Deafness and Other Communication Disorders |access-date=December 16, 2017|date=2015-08-18 }}</ref>

When a person's speech is insufficient, different kinds of [[augmentative and alternative communication]] could be considered such as alphabet boards, pictorial communication books, specialized software for computers or apps for tablets or smartphones.<ref>{{Cite journal|last=Russo|first=Maria Julieta| name-list-style = vanc |date=2017|title=High-technology Augmentative Communication for adults with post-stroke aphasia: a systematic review|journal=Expert Review of Medical Devices|volume=April 26|issue=5|pages=355–370|pmid=28446056|doi=10.1080/17434440.2017.1324291|s2cid=10452302|hdl=11336/40999|hdl-access=free}}</ref>

When addressing Wernicke's aphasia, according to Bakheit et al. (2007), the lack of awareness of the language impairments, a common characteristic of Wernicke's aphasia, may affect the rate and extent of therapy outcomes.<ref>{{cite journal |vauthors=Bakheit AM, Shaw S, Carrington S, Griffiths S |date=October 2007 |title=The rate and extent of improvement with therapy from the different types of aphasia in the first year after stroke |journal=Clinical Rehabilitation |volume=21 |issue=10 |pages=941–949 |doi=10.1177/0269215507078452 |pmid=17981853 |s2cid=25995618}}</ref> Robey (1998) determined that at least 2 hours of treatment per week is recommended for making significant language gains.<ref name=":5" /> Spontaneous recovery may cause some language gains, but without speech-language therapy, the outcomes can be half as strong as those with therapy.<ref name=":5" />

When addressing Broca's aphasia, better outcomes occur when the person participates in therapy, and treatment is more effective than no treatment for people in the acute period.<ref name=":5" /> Two or more hours of therapy per week in acute and post-acute stages produced the greatest results.<ref name=":5" /> High-intensity therapy was most effective, and low-intensity therapy was almost equivalent to no therapy.<ref name=":5" />

People with global aphasia are sometimes referred to as having irreversible aphasic syndrome, often making limited gains in auditory comprehension, and recovering no functional language modality with therapy. With this said, people with global aphasia may retain gestural communication skills that may enable success when communicating with conversational partners within familiar conditions. Process-oriented treatment options are limited, and people may not become competent language users as readers, listeners, writers, or speakers no matter how extensive therapy is.<ref name="Brookshire 2007" /> However, people's daily routines and quality of life can be enhanced with reasonable and modest goals.<ref name="Brookshire 2007" /> After the first month, there is limited to no healing to language abilities of most people. There is a grim prognosis, leaving 83% who were globally aphasic after the first month that will remain globally aphasic at the first year. Some people are so severely impaired that their existing process-oriented treatment approaches offer no signs of progress, and therefore cannot justify the cost of therapy.<ref name="Brookshire 2007" />

Perhaps due to the relative rareness of conduction aphasia, few studies have specifically studied the effectiveness of therapy for people with this type of aphasia. From the studies performed, results showed that therapy can help to improve specific language outcomes. One intervention that has had positive results is auditory repetition training. Kohn et al. (1990) reported that drilled auditory repetition training related to improvements in spontaneous speech, Francis et al. (2003) reported improvements in sentence comprehension, and Kalinyak-Fliszar et al. (2011) reported improvements in auditory-visual short-term memory.<ref>{{cite journal |vauthors=Kalinyak-Fliszar M, Kohen F, Martin N |date=January 2011 |title=Remediation of language processing in aphasia: Improving activation and maintenance of linguistic representations in (verbal) short-term memory |journal=Aphasiology |volume=25 |issue=10 |pages=1095–1131 |doi=10.1080/02687038.2011.577284 |pmc=3393127 |pmid=22791930}}</ref><ref>{{cite journal |last1=Francis |first1=Dawn |last2=Clark |first2=Nina |last3=Humphreys |first3=Glyn |name-list-style=vanc |year=2003 |title=The treatment of an auditory working memory deficit and the implications for sentence comprehension abilities in mild 'receptive' aphasia |journal=Aphasiology |volume=17 |issue=8 |pages=723–750 |doi=10.1080/02687030344000201 |s2cid=145088109}}</ref><ref>{{cite journal |vauthors=Kohn SE, Smith KL, Arsenault JK |date=April 1990 |title=The remediation of conduction aphasia via sentence repetition: a case study |journal=The British Journal of Disorders of Communication |volume=25 |issue=1 |pages=45–60 |doi=10.3109/13682829009011962 |pmid=1695853}}</ref>

===Individualized service delivery===
Intensity of treatment should be individualized based on the recency of stroke, therapy goals, and other specific characteristics such as age, size of lesion, overall health status, and motivation.<ref name="Cherney 2011">{{cite journal | vauthors = Cherney LR, Patterson JP, Raymer AM | title = Intensity of aphasia therapy: evidence and efficacy | journal = Current Neurology and Neuroscience Reports | volume = 11 | issue = 6 | pages = 560–569 | date = December 2011 | pmid = 21960063 | doi = 10.1007/s11910-011-0227-6 | s2cid = 10559070 }}</ref><ref name="Sage 2011">{{cite journal | vauthors = Sage K, Snell C, Lambon Ralph MA | title = How intensive does anomia therapy for people with aphasia need to be? | journal = Neuropsychological Rehabilitation | volume = 21 | issue = 1 | pages = 26–41 | date = January 2011 | pmid = 21181603 | doi = 10.1080/09602011.2010.528966 | s2cid = 27001159 | url = https://www.research.manchester.ac.uk/portal/en/publications/how-intensive-does-anomia-therapy-for-people-with-aphasia-need-to-be(b982a0b5-3bd8-41ba-ba2b-b847318cd3c9).html }}</ref> Each individual reacts differently to treatment intensity and is able to tolerate treatment at different times post-stroke.<ref name="Sage 2011" /> Intensity of treatment after a stroke should be dependent on the person's motivation, stamina, and tolerance for therapy.<ref name="Palmer 2015">{{cite journal|author=Palmer R|year=2015|title=Innovations in aphasia treatment after stroke: Technology to the rescue|journal=British Journal of Neuroscience Nursing|volume=38|pages=38–42|doi=10.12968/bjnn.2015.11.sup2.38}}</ref>